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ER Rotation PA-S2 > CVD > Flashcards

CVD Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Endocarditis Sx

A

Fever, New Murmur, Janeway lesions (nontender on palms/soles), Osler’s nodes (tender nodules of finger/toe pads), Roth spots (red retinal lesions w. pale centers

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2
Q

Endocarditis Dx

A

Modified Duke Criteria
TEE
positive blood cultures

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3
Q

Endocarditis Tx

A

Empiric tx = vancomycin + ceftriaxone Prosthetic valve = add rifampin & gentamicin

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4
Q

Arrhythmias

A

An abnormality in the timing or pattern of the heartbeat caused by a variety of things
Brady or tachy

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5
Q

Cardiac Tamponade Sx

A

Becks triad: hypotension, JVD, muffled heart sounds

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6
Q

Becks triad

A

Hypotension, JVD, muffled heart sounds

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7
Q

Cardiac tamponade Dx

A

EKG: Sinus tachy, low voltage, electrical alternans
POCUS triad (US): Pericardial fluid, RV diastolic collapse, Dilated IVC

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8
Q

Cardiac Tamponade Tx

A

Pericadiocentesis

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9
Q

Chest Pain

A

Nonspecific, can be caused by a variety of disorders like MI’s, anginas, pneumonia, PE

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10
Q

AFib Dx

A

EKG: No identifiable P waves, varying R-R intervals

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11
Q

AFib Sx

A

Unexplained fatigue, palpitations, fainting, SOB, chest pain, stroke (common from left atrial appendage)

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12
Q

AFib Tx and management

A

Anticoagulation: rivaroxaban, apixaban, dabigatran, edoxaban, warfarin, heparin
Rate control – older, preserved EF, asymptomatic. Rx = BB, CCB
Rhythm control – younger, symptomatic, EF <45%, new onset

Cardioversion or ablation if the above doesnt work

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13
Q

CHA2DS2-VASc

A

Anticoagulation if score is 2+.
1 pt: CHF, HTN, DM, Vascular disease (MI, PAD, atherosclerosis), age 65-74, female
2 pt: age 75+, stroke/TIA

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14
Q

Atrial Flutter dx

A

EKG: Produces a classic “sawtooth” pattern of atrial activity with lack of P waves

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15
Q

Atrial Flutter Tx

A

Anticoagulation

Cardioversion, if hemodynamically unstable

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16
Q

SVT definition

A

Rapid rhythm disturbances originating from the atria or the atrioventricular node (narrow complex)

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17
Q

SVT Sx

A

Abrupt onset, heart racing/palpitations, SOB, diaphoresis, chest pain, rapid breathing, dizziness, loss of consciousness

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18
Q

SVT dx

A

EKG: narrow QRS complex, usually 160-220 bpm, rate does not vary

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19
Q

SVT Tx

A

Physical maneuver if isolated incidences (valvsalva, hold breath, head btw knees, ice water)
IV Adenosine (in acute setting) Only give adenosine if narrow QRS
Send for EP study (stable), cardiovert (if unstable)
Ablation (definitive treatment)

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20
Q

LBBB vs RBBB

A

LBBB= wide QRS (>0.12s), will have –> think batman
RBBB = left ventricle depolarizes first, then right (b/c that’s where delay is) –> think rabbit ears
V1, V2 = RBBB
V5, V6 = LBBB

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21
Q

VTach EKG findings and Sx

A

EKG: Wide QRS (>120ms) originating from ventricles (rate >100)
Sx: May present as syncope +/- hemodynamic stability

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22
Q

VTach Tx (initial vs long term)

A

Initial: Urgent cardioversion, IV amiodarone
Long-term: reverse cause, BB if structural heart disease, ablation, ICD if cardiomyopathy/EF<35% after GDMT

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23
Q

Torsades de pointes causes, EKG findings, and Tx

A

Cause: commonly hypomagnesemia if electrolyte disturbance
Clinical Pearl: Prolonged QT interval = higher risk of developing polymorphic VT
Tx: IV magnesium

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24
Q

VFib EKG findings and tx
What happens to ventricles during VFib?

A

Main cause of sudden cardiac death in pts w. MI
Ventricles quivering w. no forward cardiac output
EKG: Chicken scratch
Tx: ACLS (defibrillation, epinephrine, antiarrhythmics)

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25
Q

PVC definition

A

Premature, ectopic, wide complexes, compensatory pause

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26
Q

PVC Sx

A

Most asymptomatic, can feel heart skip a beat

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27
Q

What are PVC’s associated with?

A

May be associated w. caffeine, energy drinks, stress, electrolyte abnormalities, hyperthyroidism

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28
Q

PVC tx (symptomatic vs asymptomatic)

A

Asymptomatic: None
Symptomatic: 1st line is beta-blockers or non-dihydropyridine CCB.

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29
Q

PAC definition

A

An extra heartbeat that occurs occasionally, often for no known reason, momentarily throwing off the heart’s normal rhythm

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30
Q

STEMI labs

A

Positive troponin or CK-MB
Positive as early as 4-6 hrs after MI onset, abnormal by 8-12 hrs
May remain elevated 5-7 days+
CK-MB generally normalizes w/in 24 hrs

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31
Q

STEMI EKG

A

Peaked “hyperacute” T waves
ST-segment elevation
Q wave development or old infarct
T wave inversion
New LBBB – considered STEMI equivalent until proven otherwise (reference old EKGs)

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32
Q

STEMI Sx

A

Chest pain
Shortness of breath or trouble breathing
Nausea, stomach pain or discomfort
Heart palpitations
Anxiety or a feeling of impending doom.
Sweating.
Feeling dizzy, lightheaded or fainting.

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33
Q

Anterior wall MI: EKG leads and location in heart

A

Think about septum & left ventricle
V2-V4: anterior wall
LAD (affects LV = more prone to LV heart failure)
Prone ventricular arrythmias/ shock

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34
Q

Lateral wall MI: EKG leads and location in heart

A

I, aVL, V5, V6
Left Circumflex Artery

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35
Q

Inferior wall MI: EKG leads and location in heart

A

Think right ventricle & SA/AV node
II,III,aVF
Right Coronary Artery
Give IV fluids
Pre-load dependent = caution w. nitro & morphine

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36
Q

Tx of STEMI, NSTEMI and unstable angina

A

MONA-BAS
Morphine – chest discomfort after NTG; watch bp/pulse
Oxygen – supplemental
Nitroglycerine
Aspirin – 162-325 mg loading dose
Beta blockers (oral, IV. Watch BP/HR)
Antiplatelet (Clopidogrel, prasugrel, ticagrelor)
Anticoagulation (Heparin: enoxaparin [lovenox] or unfractionated heparin)  per doctor in ER if troponin is (+) add heparin
Statin (Atorvastatin, rosuvastatin)
+/- cath

37
Q

Stable Angina definition and sx

A

Chest wall discomfort precipitated by stress or exertion and relieved by rest or nitrates
Sx: pressure, pain, squeezing, tightness, heaviness…
Sx’s are EXERTIONAL and RELIEVED WITH REST
<20 minutes duration

38
Q

Stable angina labs and imaging

A

Negative troponin/CK-MB
EKG: Resting EKG is often normal. Possible Ischemic changes: ST depression, T wave flattening or inversion
Stress test w or w/o imaging (myocardial perfusion scan or stress echo)
Cardiac CTA

39
Q

Stable angina Tx

A

1st line: Beta-blockers – prolongs life (first line therapy)
Aspirin 81-325 mg or clopidogrel 75 mg

2nd line: long acting nitrates

40
Q

Unstable anginas/NSTEMI CP typically lasts (GREATER/LESS) than ____ minutes

A

Greater than 30 minutes

41
Q

What differentiates an NSTEMI vs unstable angina?

A

Positive troponin in NSTEMI

42
Q

EKG findings in unstable angina/NSTEMI

A

ST depression

43
Q

What is the criteria for ST elevation on EKG?

A

ST segment must be elevated greater than 2 mm (aka greater than 2 small boxes)

44
Q

What medication will you give in a STEMI but NOT an NSTEMI?

A

Fibrinolytic therapy

45
Q

Definition of Prinzmetal’s/Variant Angina + what causes it

A

Known as coronary vasospasm
Angina pain usually at rest (often b/w midnight-early morning) with no change in exercise function
More common in women < 50
May be induced by exposure to cold, emotional stress, or vasoconstricting medications
Usually involves right coronary artery (RCA)

46
Q

EKG findings in Prinzmetal’s/Variant Angina

A

ST elevation- gets confused for STEMI

47
Q

How to dx Prinzmetal’s/Variant Angina and how to tx

A

Dx: EKG and CTA
Tx: CCB and/or nitrates

48
Q

Definition of DOE

A

Difficulty breathing that is elicited with physical activity. Presents in a variety of CVD and pulm disorders

49
Q

Definition of edema

A

Swelling caused by fluid trapped in your body’s tissues
Typically seen in LE dt gravity
Can be seen dt infection/inflammation

50
Q

Sx of CHF

A

DOE, SOB, orthopnea, edema, abdominal bloating/distention, cough, decreased appetite

51
Q

Differentiate right vs left sided CHF

A

Left-sided:
Rales/crackles/wheezes
Dullness to percussion
S3, S4 or gallop

Right-sided:
Distended neck veins, elevated JVP (>8 cm)
Abdominal distention
Pedal edema (1-4+)
Hepatojugular Reflux
Ascites
Liver enlargement/tenderness

52
Q

CHF labs and Dx

A

Labs: BNP, CBC, CMP
Dx: Echo, EKG, CXR

53
Q

What CXR findings can be seen in CHF?

A

A: Alveolar edema (bat wing opacities)
B: Blunting of margins, Kerley B lines
C: Cardiomegaly
D: Dilated upper lobe vessels
E: Pleural effusion, Pulmonary edema

54
Q

CHF tx

A

BASS
 SGLT2-I
 ARNI/ACE/ARB
 Spironolactone (MRA)
 BB (metoprolol or carvedilol)

Furosemide if wet CHF

55
Q

What are EKG findings in Atrial enlargement/hypertrophy (RAE/LAE)? What lead should you look at?

A

Look at lead 2
RAE: taller P wave (kinda looks like mountain with small notch)
LAE: wider, notched P wave (looks like 2 boobs)

56
Q

Hypertensive urgency vs emergency
Goal reduction
BP presenting
Signs/Sx
Tx

A

Urgency:
Goal: reduce BP in hours
BP: >180/120
Signs/Sx: +/- HA/CP, NO evidence of end organ damage
Tx: outpatient po – ACTS meds

Emergency:
Goal: Reduce BP 10-20% in 1 hour
BP: >180-220/120
Signs/Sx: Evidence of end organ damage
Tx: inpatient IV (labetalol)

56
Q

EKG findings of LVH

A

Larger S in V1, larger R in V5 (if greater than 35 mm = LVH)
Seaman’s sign: R waves touch S waves
T waves typically inverted

57
Q

EKG findings in RVH

A

Reverse R wave progression
Normally R wave increases V1 –> V6
RVH: Larger R wave and smaller S in V1

58
Q

Cardiogenic hypotension: definition, causes, Sx and Tx

A

Volume maintained, decreased CO, incr. resp. effort
MI, myocarditis, valvular disease, congenital heart disease, cardiomyopathy, arrhythmias
Sx: Decrease cardiac output, hypotension, vasoconstriction (incr. SVR)
Tx: Oxygen, fluid resuscitation

59
Q

Orthostatic hypotension causes and Sx

A

Aka postural hypotension
Hypotension when standing up after sitting/laying down
Can be dt blood loss, vasodilators, diuretics
Sx:
* Lightheadedness or dizziness upon standing
* Blurry vision
* Weakness
* Fainting (syncope)
* Confusion

60
Q

How to manage orthostatic hypotension (medication vs non medication)

A

Non medical Management:
* External compression devices such as waist-high compression stockings
* Physical maneuvers such as lunges, calf-raise, squatting, leg crossing
* Increase water and fluid intake to about 2-3 liters per day, avoid dehydration
* Increase salt in diet 6-10g/day
* Raising the head of the bed to 10 degrees at night

Medication Management: Goal = incr. blood volume
* Midodrine 2.5 to 15mg PO QD to TID
* Fludrocortisone 0.1 to 0.2mg daily in AM titrated up to 1mg daily PRN
* Pyridostigmine 30 to 60 mg PO TID
* Yohimbine 5.4 to 10.8mg PO TID
* Octreotide 12.5 to 50 ug subcutaneously BID
* Cafergot such as caffeine 100mg and ergotamine 100mg

DONT NEED TO KNOW MEDICATIONS (probably)

61
Q

Definition of orthopnea and how to relieve it

A

o SOB whilst laying down
o Relieved by sitting up
o Typically seen in CHF, pericarditis, Pericardial effusion/tamponade, pleural effusion
o Tx underlying cause

62
Q

Pericardial effusion definition and Sx

A

Definition: Extra fluid in pericardial space creates pressure on heart chambers
Sx:
Asymptomatic (depends on size/effect)- incidental finding
Constant dull ache, tachycardia, hypotension, JVD, Pulsus paradoxus (blood pressure decreases with inhalation), dysphagia, dyspnea,
Becks triad
* Muffled heart sounds
* Increased JVP
* Hypotension
Dullness to percussion L lung over angle of scapula (Ewart’s sign)

63
Q

Pericardial effusion Dx (and their findings) and labs

A

Labs: CBC, CMP, BNP, ANA
Dx:
EKG: low QRS voltage with sinus tach, electrical alternans
CXR: enlarged cardiac silhouette with clear lungs
Can do echo to quantify effusion and assess hemodynamic impact

64
Q

PVD/PAD causes, RF, and clinical findings

A

Systemic atherosclerosis
Risk Factors: CAD, HTN, male, dyslipidemia, incr. age. Diabetes, metabolic syndrome, tobacco use
Clinical Findings
 Intermittent claudication
 Cramping pain in the lower extremities
 Induced by activity, relieved with rest
 Cool skin temperature
 Pale skin color
 Scant hair distribution
 Weak distal pulses
 Nonhealing wounds

65
Q

How to dx and manage PAD/PVD

A

Dx: Ankle Brachial Index (ABI) (an ultrasound)
* Normal: 1.0-1.4
* PAD: < 0.90
* Severe disease: < 0.5
CT angiography (Gold standard) or MRA
Management
 Antiplatelet Therapy
 Clopidogrel
 Aspirin
 High-intensity Statin Therapy
 Risk factor modification

66
Q

Sx of syncope

A

 Lightheadedness.
 Feeling unstable in the upright position.
 Warm or cold/clammy.
 Sweating.
 Palpitations
 Nausea, vomiting, or nonspecific abdominal discomfort.
 Visual “blurring”

67
Q

Differentiate between vasovagal syncope, carotid sinus hypersensitivity, cardiogenic syncope, and situational syncope. How do you manage/tx?

A

Vasovagal syncope - “common faint. Caused by stressful, painful, or claustrophobic experience

Carotid sinus hypersensitivity: Stimulation of abnormally sensitive carotid body, with subsequent abnormal vagal response. Results in bradycardia and arterial relaxation/dilation

Situational syncope: Enhanced vagal tone with resulting hypotension. Coughing, sneezing, micturition, exercise

Cardiogenic syncope: Mechanical or arrhythmic basis arising from heart. Brady: Sinus brady, sinus pauses, AV block
Tachy: Ventricular tachycardia
Mechanical: Aortic stenosis, Pulmonary stenosis, hypertrophic cardiomyopathy, congenital lesions, massive PE

Tx:
 Trigger avoidance
 Increase fluids and salt
 Compression stockings
 Counterpressure maneuvers – Reduce venous pooling & improve cardiac output or move to supine position
 Leg-crossing with simultaneous tensing of leg, abdominal, and buttock muscles (very effective).
 Handgrip – maximum grip on a rubber ball or similar object

68
Q

Aortic stenosis:
Sx
PE
Dx
Tx

A

Narrowing of aortic valve
Sx: asymptomatic, SAD (syncope, angina, dyspnea), HF result of LV dysfunction
PE: Harsh crescendo-decrescendo systolic murmur (heard best@ RUSB)
S1 is usually unaffected, as AS progresses S2 diminishes and can eventually disappear
Dx: TTE, EKG (can be normal, LVH, left atrial enlargement)
Tx: Valve replacement, Lifelong anticoagulation, TAVR

69
Q

Aortic regurgitation causes (acute vs chronic), Sx, PE, Tx

A

Causes:
* Acute: Infective endocarditis, Marfan’s syndrome, Aortic dissection*, Acute prosthetic valve dysfunction, Inflammatory disease, Dilated CM
* Chronic: bicuspid valve, dilated CM

Sx: Asymptomatic, Exertional dyspnea, Fatigue, Atypical chest pain, Eventual LV dilation & failure, Orthopnea/PND

PE: Displaced PMI lateral to midclavicular line in 5th intercostal space
Diastolic thrill maybe palpable in 2nd left intercostal space
* Wide pulse pressure (big difference in SBP and DBP)
* Water Hammer Pulse: Collapsing pulse. Rapid swelling & falling arterial pulse. Best on radial/brachial/carotid pulses.
* Corrigan Pulse: Similar to water hammer but referring to carotid artery
* Hill’s Sign: Popliteal cuff systolic pressure > brachial pressure by more than 60 mmHg while recumbent. Most sensitive for AI.
* Muller’s Sign: visible systolic pulsations of the uvula
* De Musset’s Sign: Head-bobbing with each heartbeat
* Becker’s Sign: Visible pulsations of retinal arteries & pupils
* Rosenbach’s Sign: Systolic pulsations of liver
* Gerhard’s Sign: Systolic pulsations of spleen

Tx:
Mild: vasodilators (hydralazine), diuretics, BB, CCB, ACE
Severe:
Surgery: TAVR, aortic root replacement

70
Q

Mitral regurgitation Sx (acute vs chronic), PE, Dx, Tx

A

Sx:
Acute MR: sudden onset SOB, orthopnea, LE edema, possible cardiogenic shock
Chronic MR: asymptomatic for yrs, then exertional dyspnea & intolerance. Fatigue, orthopnea & PND as MR progresses. Palpitations: possible atrial fibrillation as a result of LA dilation

PE:
High-pitched blowing Holosystolic murmur
Heard best at apex (may radiate to axilla)
Possible S3

Dx:
Echo (regurgitant volume, EF, LA/LV size, PA pressure, RV function)
BNP (early identifier of LV dysfunction)
CXR (acute vs. chronic MR)

Tx:
Meds:
o Vasodilators: hydralazine, ACE
o Diuretics
o Anticoag if Afib
Surgery
* Acute severe MR (urgent): stabilize w. vasodilators to incr. pulm. Pressure & maximize forward flow
* Chronic severe MR (elective): if reduced EF or LV dilation w. reduced contractility

71
Q

Abdominal Aortic Aneurism who to screen

A

90% originate below renal arteries
Involvement of the aortic bifurcation
Screening:
o Abdominal ultrasound
o Men 65-75 years-old
o Family history (1st degree relative)
o Smoking history (current or past)

72
Q

Abdominal Aortic Aneurism clinical findings (asymptomatic vs symptomatic)

A

Asymptomatic: Incidental finding on abdominal ultrasound or CT imaging

Symptomatic: Sign of rapid expansion or impending rupture
 Mild to severe deep abdominal or flank pain that is constant or intermittent
 Exacerbated upon palpation
 Pain radiates to back

73
Q

Risk of AAA rupture increases drastically when diameter is > _____

A

Risk of AAA rupture increases drastically when diameter is > 5.5 cm

74
Q

AAA initial screening vs assessing diameter

A

initial: US
assessing: Abdominal CT w. contrast to assess diameter & for surgical planning

75
Q

When to refer for surgical repair for AAA

A

o Diameter > 5.5 cm
o Rapid diameter expansion (> 0.5 cm in 6 months)
o Symptomatic – Pain, tenderness

76
Q

What are clinical findings of a TAA

A

Symptoms dependent upon size & position of aneurysm & rate of growth
 Esophagus: dysphagia
 Trachea: stridor, dyspnea
 Superior vena cava: Upper extremity edema, JVD
 Aortic root: Aortic regurgitation
 Substernal chest pain
 Pain radiating to the back or neck

77
Q

What imaging is used to determine a TAA

A

Chest radiographs: useful initial evaluation, not sensitive or specific
CT Angiography: Best initial imaging for patients suspected to have TAA
TEE or TTE

78
Q

Surgical indications for TAA

A

Diameter > 5.5 cm
All symptomatic TAAs require surgical repair

79
Q

An aortic dissection occurs when there is a spontaneous tear of the ____ _____

A

Spontaneous tear of tunica intima

80
Q

What is the number one cause of aortic dissection?

A

HTN

81
Q

Clinical findings of aortic dissection

A
  • Sudden onset severe, persistent chest pain described as ripping, sharp, tearing
  • Pain radiates in respect to location & extent down the back, anterior chest and/or neck
  • Hypertension
  • Syncopal episodes
  • Diminished peripheral pulses
  • Variations in pulses and blood pressure when comparing extremities
82
Q

Aortic dissection imaging

A

EKG
Chest Radiograph (x-ray): Widening of mediastinum/aortic silhouette
CT of chest & abdomen: Immediate diagnostic imaging of choice
TEE

83
Q

Aortic dissection tx and management

A

Surgical Repair
Management and Disposition
* Aggressive blood pressure control
o Reduce to 100-120 mmHg systolic
* Beta blockers are the first-line management
o Labetalol
* Nitroprusside

84
Q

Differentiate between thrombus and embolus

A

Thrombus
* Blood clot results from ruptured atherosclerotic plaque or stagnant blood flow from cardiac arrhythmia
* Occlusion of small, distal arteries
* History of peripheral artery disease

Embolus
* A blood clot arising from the vascular system that travels to a distal area, causing occlusion
* Occlusion of larger arteries
* History of cardiac event

85
Q

Clinical findings of arterial occulsion

A

Abrupt onset pain in extremity
The 5 P’s
o Pain
o Pulselessness
o Pallor
o Paralysis
o Paresthesia
o Limb is cool to touch
o Degree of ischemia is related to collateral blood flow

86
Q

Arterial occlusion dx and tx

A

Dx – typically done off physical Exam Findings & Arterial/Venous Doppler Findings
Diagnostics:
* Vascular Sonography
* Arterial Doppler Ultrasound
* CT Angiography
* Delayed intervention

Tx
* Anticoagulation
* Unfractionated Heparin IV
* Catheter-directed thrombolysis
* tPA (Tissue plasminogen activator)
* Thromboembolectomy
* Revascularization must take place within 3 hours

87
Q

Thrombophlebitis: RF, presentation, PE, Dx, Tx

A

Risk Factors: virchows triad (venous stasis, vascular injury, hyper coagulability)

Presentation:
o Dull pain
o Erythema
o Tenderness
o Palpable induration or cord
o Most common presentation on PANCE questions will be patient post trauma, or at IV/PICC site

Physical exam: erythema, tenderness, cord
Dx: Ultrasound: r/o deep vein involvement or occlusion

Treatment
o Rest
o Warm compresses, heat
o Elevation
o NSAIDS

ER Rotation PA-S2 (11 decks)

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